CurrentProvidence Health PlanPolicy N/A

Medicare Part B Drug Prior Authorization (Providence Medicare Advantage Plans)

Defines Providence Medicare Advantage Plans' prior authorization requirements for certain Medicare Part B drugs (drugs administered/infused or otherwise billed under Part B) and lists the HCPCS/J-codes and associated medication names subject to prior authorization. Affects providers and facilities administering Part B drugs to Providence Medicare Advantage members.

Policy Summary

PayerProvidence Health Plan

PolicyMedicare Part B Drug Prior Authorization (Providence Medicare Advantage Plans)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit and obtain prior authorization for listed Medicare Part B drugs per the linked, medication-specific criteria before administration to avoid claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~320+Part B medication entries listed (J/Q/C/S codes)

~170Listed codes and drug entries in this segment

5/1/2026Policy effective date

Providence MAPayer

503-574-8000

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Coverage Criteria

General prior authorization requirement

Covered when prior authorization criteria for each listed medication are met and approved per the medication-specific criteria (linked in the list).

General requirement: Prior authorization request submitted and approved for the specific Part B drug/code per its referenced policy criteria

Providers must follow medication-specific criteria linked in the list

General prior authorization requirement

Covered when prior authorization is obtained per the linked drug-specific criteria

Listed drug and code: The drug is one of the listed Medicare Part B medications with an associated HCPCS/J/Q/C code and a linked policy criteria document.

Refer to the individual document link for clinical coverage criteria.

HCPCS / J / Q / C Codes (Part B drugs)

Provider Actions & Prior Authorization Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for the Part B drugs and HCPCS/CPT codes listed below. Providers must obtain prior authorization before administration to avoid claim denial.

Affected codes: all HCPCS/CPT codes listed in the table of Medicare Part B drugs in this document (examples include Q2055, J9264, J3262, J0791, J9042, J9029, J7171, J1931, J7173, J9057, ... through J9345).
Failure to obtain prior authorization may result in services not being covered.

Documentation Required

Required documentation and policy link

For each listed drug code there is a linked policy criteria document that explains the clinical criteria, required supporting documentation, and any limits (e.g., step therapy, quantity or duration limits). Review the linked criteria before submitting an authorization request.

Each drug entry includes a "Document Link (click to view the policy criteria) = Click to view."

Background

Prior authorization is a process Providence Medicare Advantage Plans uses to ensure appropriate use of certain medications before the plan agrees to cover them. This policy requires providers to obtain approval in advance for selected Medicare Part B drugs—frequently specialty agents given by injection or infusion—so the plan can confirm the therapy meets the plan's clinical criteria and is being used in the right setting. Failure to request and receive prior authorization before administration may result in the drug not being covered by the plan.

This document serves as the consolidated listing of Part B drugs subject to prior authorization and links each listed HCPCS/J/Q/C code to the medication-specific policy criteria (see the drug entries and their "Document Link" fields). For questions or assistance with prior authorization, providers may contact Providence Medicare Advantage Plans at the phone numbers listed on the policy.

Definitions and Key Fields

Document Link

Document LinkClick to view (opens the drug-specific prior authorization criteria document)

Effective Date

Effective DateEffective 5/1/2026

Note

Link and effective date per drug/code

Each drug/code row in the Part B list includes a Document Link and an Effective Date field. Providers should click the Document Link to view the specific criteria and note the Effective Date when present (for example, Gazyva J9301 lists Effective Date = 5/1/2026; Yartemlea J3590/C9400 lists Effective Date = 5/1/2026; Vykoura J3490/C9399 lists Effective Date = 3/1/2026; Tyruko Q5134 lists Effective Date = 2/1/2026).

If the Effective Date is blank, the current criteria are in effect as of 1/1/2026 or earlier.
Examples of codes with listed effective dates: J9301 (Gazyva) = 5/1/2026; J3590/C9400 (Yartemlea) = 5/1/2026; J3490/C9399 (Vykoura) = 3/1/2026; Q5134 (Tyruko) = 2/1/2026.

Step Therapy

Step / criteria referenced on linked pages

The linked policy criteria pages include step/criteria logic that may require specific prior steps be met before approval (for example: previous therapies tried, diagnosis documentation, dosing limits, or grouped rules for enteral B-codes and TPN codes). Follow the step-therapy and criteria nodes on the linked pages when preparing the authorization request.

Grouped criteria examples: enteral nutrition codes (B4034–B4160 series) and total parenteral nutrition codes (B4164–B5100 series) may have grouped clinical requirements.
Authorization requests should document fulfillment of initial and continuation criteria where applicable (e.g., prior treatment history, lab results, weight/height for nutrition products).